Presentation on theme: "Facial Injuries ATTR 650. Case Study Quiz A baseball player waiting his turn on deck receives a direct blow to the upper row of teeth by a baseball bat."— Presentation transcript:
Facial Injuries ATTR 650
Case Study Quiz A baseball player waiting his turn on deck receives a direct blow to the upper row of teeth by a baseball bat being swung by the person next to him. –Short list of injuries –Tx –Referral 2 1
Case Study Quiz A 14 YO basketball player is struck in the nose by an opponent's elbow while grabbing a rebound. He runs to the bench holding his nose, which is now pouring blood.This is what you see after stopping the bleeding.(procedures to stop) –Short list of injuries –Evaluate, TX –Referral 2 1
Facial Bones Frontal bone Bony orbit - superior, inferior, medial and lateral Zygomatic Nasal - external and internal (posterior - ethmoid, vomer and maxillary) Maxilla Mandible
Facial bones Anterior Posterior
Soft Tissue Eye Ear TMJ joint –Mandible and temporal bone –Ligaments –Joint capsule –Meniscus between the condyle of mandible and articular surface of temporal bone (concave articular fossa and convex articular eminence)
Nasal soft tissue Cartilage of the nose –external = lateral and alar cartilage –internal = quadrangular cartilage and membranous septum which separates it from the alar cartilage distally Septum divides into 2 passages (2-4 mm) –Proximal half is skeletal - vertical plate of ethmoid, vomer, & minimal portions of palatine and maxillary bones
Facial Muscles Muscles of facial expression and mastication Eye muscles –Superior, inferior, medial and lateral rectus –Superior and inferior oblique m (move eye superiorly & medially, inferiorly & laterally)
Tx Depends on the size of the defect and the amount of entrapment. In the absence of diplopia, even in extreme up gaze, no treatment may be indicated but is usually offered in large defects where there is concern about prolapse of orbital fat and subsequent enophthalmos or entrapped tissue with persisting vertical diplopia. Surgical repair is best carried out within 10 days of the injury.
Evaluation & Tx crepitus If zygomatic arch may see dimpling with bone intact If unstable repair right away Lift up and out as it snaps back in (intra or extra orally)
Pathophysiology Frontal force - Causes damage ranging from simple fracture of the nasal bones to flattening of the entire nose Lateral force - May depress only one nasal bone; with sufficient force, both bones may be displaced; can cause severe septal displacement, which can twist or buckle the nose; septal fragments may interlock, creating difficulty in reduction Superior-directed force (from below) - Rarely occurs; may cause severe septal fractures and dislocation of the quadrangular cartilage
Clinical Findings Epistaxis – Common in nasal fractures due to mucosal disruption Change in nasal appearance Nasal airway obstruction Infraorbital ecchymosis for CSF fluid
Septal Hematoma Possibility of septal hematoma – gentle palpation reveals it is soft and compressible needle aspiration or vertical mucosal incision and drainage firm anterior layered gauze pack to keep the septal mucosa pressed firmly against the cartilage.
Evaluation X-rays are controversial - studies have shown that radiographs are not helpful in the diagnosis or management of nasal fractures. Old fractures, vascular markings, and suture lines can lead to false-positive results. CT scan is more useful to assess for other associated injuries, as well as extent of nasal injury. Because the nose occupies such a prominent and accessible position, careful examination is possible and may obviate any need for radiographic study. Photographs are useful for documentation and for comparison with pre-injury photos.
Tx Elevation of head and cold compresses Closed or open reduction within 2 weeks of the fracture. The potential for optimal results lies in the reduction of the fracture within the first several hours following the injury, before significant edema has appeared. If this window has passed, subsequent reassessment of the injury is advisable, with correction planned for approximately 7 days following the injury.
Tx Waiting at least 6 months to perform surgery allows fractures to stabilize and wounds to heal if Fx identified after significant bony healing has occurred. Post surgery – splints in place for 7-10 days when necessary. Simple closed reduction requires no packing. If packs used - continue taking antibiotics to avoid toxic shock. The use of cold compresses for 1-2 days reduces edema and discomfort.
Maxilla & Midface Fx
LeFort Classification LeFort I - transmaxillary Fx runs between the maxillary floor and the orbital floor. The floating fragment will be the lower maxilla with the maxillary teeth LeFort II - described as a pyramidal Fx because of its shape. Involves maxilla & nasal (MOI = downward blow to nasal area)
LeFort Classification LeFort III - Referred to as the craniofacial disassociation as the unstable fragment is the entire face. (A/P translation) –It involves the maxilla, bony orbit and nasal bone as well as soft tissue –MOI is a considerable force which also involves injury to the skull and brain –Use of CT scan to diagnose
Tx Open or closed reduction Incision and the use of plates or screws septal damage vitals
Smash Fx Severe comminution of the face Underlying skull injury Individual is often in unstable condition with other injuries involved
Tx Close reduction –Wire teeth together for 8-10 weeks Open reduction –Expose bone, line up and plate with titanium plates –Compress further by wiring teeth (arch bars and wire together)
Evaluation & Tx alignment – bite teeth together crepitus swelling, bleeding, numbness, pain, bruising movement inside jaw Open or closed reduction
Anatomy of the Ear
Ear Injuries Laceration of the external ear Auricular hematoma Otitis Externa - infection of external ear Tympanic membrane rupture –sudden change of air pressure caused by blunt trauma –Direct blunt trauma
Chipped Tooth – Class I and II Fx 1 2
Tx Avoid cold or warm liquids Check for exposure of pulp Do not try to locate the chipped area Refer to dentist the next day Tooth can be capped or bonded for cosmetic purposes for tooth vitality periodically
Fx – Class III, IV Splint, root canal, removal of tooth
Lateral Luxation, (Root canal for repair)
Avulsion Complete displacement of the tooth from its socket
Avulsion with possible Fx of maxilla
Tx Replant immediately if possible (within 30 min) Transport medium –A. Hank's Balanced Salt Solution (H.B.S.S.) –B. Milk – but could sour over time –C. Saline –D. Saliva (buccal Vestibule) –If none of the above is readily available, use water Never transport in gauze
Management of root surface 1. Keep the tooth moist at all times. 2. Do not handle the root surface (hold tooth by the crown). 3. Do not scrape or brush the root surface or remove the tip of the root. 4. If the root appears clean, replant as is after rinsing with saline. 5. If the root surface is contaminated, rinse with H.B.S.S. or saline If persistent debris remains on root surface, gently use cotton pliers to remove remaining debris and/or gently brush off debris with a wet sponge.
Management of the Socket 1. Gently aspirate without entering the socket. If a clot is present, use light irrigation with saline. 2. Do not curette the socket. 3. Do not vent socket. 4. Do not make a surgical flap unless bony fragments prevent replantation. 5. If the alveolar bone is collapsed and prevents replantation, carefully insert a blunt instrument into the socket to reposition the bone to its original position. 6. After replantation, manually compress (if spread apart) facial and lingual bony plates.
Suture soft tissue and splint 1. use orthodontic brackets with passive arch wire. Suture in place only if alternative splinting methods are unavailable. (circumferential wire splints are contraindicated.) 2. Splint should remain in place for 7-10 days; however, if tooth demonstrates excessive mobility, splint should be replaced until mobility is within acceptable limits. 3. Bony fractures resulting in mobility usually require longer splinting periods (2-8 weeks). 4. Home care during splinting period: no biting on splint, soft diet, good oral hygiene
Prevention and Protection – Molded Mouthguards Impression of mouth, thermoplastic material adapted over cast
Laboratory Pressure Laminated Mouthguard Laminate 2-3 layers of EVA – use of high heat & pressure